New Student Form (Our Savior Lynchburg, VA)

Student Name *

Gender *

School *

Other school name (if not listed)

Major

expected grad semester/year

Reference made by: *

LCMS student? *

Cell phone *

Email *

May we share your contact info in our church directory? (You will be given access also) *

Student Address (street, city, state, ZIP) *

Home Congregation name and city/state *

I would like to contact your home congregation to let them know you are under my pastoral care

Name of home pastor

Parents' names and emails

Parent info is helpful in case of any emergencies.

Parents' phone

Please send me info on CSER hours.

Please send me info on rides to church.

Subscribe student to church email updates?

Subscribe parents to church email updates?

Please tell us about yourself, or, if you are not the student, about the student you are referring. *